<form id="formEditObat">
		<td></td>
		<td>
		<input type="text" class="form-control input-sm" disabled="" value="<?= $obat_klaim['kode'] ?>">
		</td>
		<td>
			<input type="text" class="form-control input-sm" disabled="" value="<?= $obat_klaim['obat'] ?>">
			<input type="hidden" id="id_obat_klaim" name="id_obat_klaim" value="<?= $obat_klaim['id_detail_klaim_obat'] ?>">
		</td>
		<td>
			<input type="text" class="form-control input-sm" disabled="" id="etarif_perda" name="etarif_perda" value="<?= $obat_klaim['tarif_perda'] ?>">
		</td>
		<td align="center">
			<input type="text" class="form-control input-sm" id="ejumlah" name="ejumlah" value="<?= $obat_klaim['frekuensi_diminta'] ?>">
		</td>
		<td>
			<input type="text" class="form-control input-sm" id="etarif_diminta" name="etarif_diminta" value="<?= $obat_klaim['tarif_diminta'] ?>">
		</td>
		<td>
			<input type="text" class="form-control input-sm esubtotal" id="esubtotal" name="elsubtotal" disabled="" value="<?= ($obat_klaim['tarif_diminta']*$obat_klaim['frekuensi_diminta']) ?>">
		</td>
		<td>
			<button id="update" type="button" class="btn btn-sm btn-success btn-flat"><i class="fa fa-floppy-o"></i> Simpan</button>
			<a class="btn btn-sm btn-danger btn-flat" href="#pilih_obat" onClick="return get_apotik_klaim()"><i class="fa fa-power-off"></i></a>
		</td>
</form>